Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign

Safety concerns about the use of radiation-based imaging such as computed tomography (CT) in children have resulted in national recommendations to use ultrasound (US) for the diagnosis of appendicitis when possible. We evaluated the trends in CT and US use in a statewide sample and the accuracy of these modalities.

Patients less than or equal to 18 years undergoing appendectomy in Washington State from 2008 to 2013 were evaluated for preoperative US/CT use, as well as imaging/pathology concordance using data from the Surgical Care and Outcomes Assessment Program.

Among 3,353 children, 98.3% underwent preoperative imaging. There was a significant increase in the use of US first over the study period (P < .001). The use of CT at any time during the evaluation decreased. Despite this, in 2013, over 40% of the children still underwent CT imaging. Concordance between US imaging and pathology varied between 40% and 75% at hospitals performing greater than or equal to 10 appendectomies in 2013. Over one third (34.9%) of CT scans performed in the evaluation of children with appendicitis were performed after an indeterminate US.

Although the use of US as the first imaging modality to diagnose pediatric appendicitis has increased over the past 5 years, over 40% of children still undergo a CT scan during their preoperative evaluation. Causality for this persistence of CT use is unclear, but could include variability in US accuracy, lack of training, and lack of awareness of the risks of radiation-based imaging. Developing a campaign to focus on continued reduction in CT and increased use of high-quality US should be pursued.